1.

Regular oral hygiene is an essential intervention for the client who has A helpless client should be positioned on the side, not on the back.
had a stroke. Which of the following nursing measures is inappropriate This lateral position helps secretions escape from the throat and mouth,
when providing oral hygiene? minimizing the risk of aspiration.
1. Placing the client on the back with a small pillow under the head.  Option B: It may be necessary to suction, so having suction
2. Keeping portable suctioning equipment at the bedside. equipment at the bedside is necessary.
3. Opening the client’s mouth with a padded tongue blade.
4. Cleaning the client’s mouth and teeth with a toothbrush.
 Option C: Padded tongue blades are safe to use.
2. A 78-year-old client is admitted to the emergency department with  Option D: A toothbrush is appropriate to use.
numbness and weakness of the left arm and slurred speech. Which nursing 2. Answer: 3. Schedule for A STAT computer tomography (CT) scan of the
intervention is a priority? head.
1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). A CT scan will determine if the client is having a stroke or has a brain tumoror
2. Discuss the precipitating factors that caused the symptoms. another neurological disorder. This would also determine if it is a
3. Schedule for A STAT computer tomography (CT) scan of the head. hemorrhagic or ischemic accident and guide the treatment because only an
4. Notify the speech pathologist for an emergency consult. ischemic stroke can use rt-PA. This would make (1) not the priority since if a
3. A client arrives in the emergency department with an ischemic stroke stroke was determined to be hemorrhagic, rt-PA is contraindicated.
and receives tissue plasminogen activator (t-PA) administration. Which is  Option A: rt-PA is contraindicated.
the priority nursing assessment?  Options B and D: Discuss the precipitating factors for teaching
1. Current medications. would not be a priority and slurred speech would as indicate
2. Complete physical and history. interference for teaching. Referring the client for speech therapy
3. Time of onset of current stroke. would be an intervention after the CVA emergency treatment is
4. Upcoming surgical procedures. administered according to protocol.
4. During the first 24 hours after thrombolytic therapy for ischemic stroke, 3. Answer: 3. Time of onset of current stroke.
the primary goal is to control the client’s: The time of onset of a stroke to t-PA administration is critical. Administration
1. Pulse within 3 hours has better outcomes.
2. Respirations
 Option A: Current medications are relevant, but the onset of
3. Blood pressure
current stroke takes priority.
4. Temperature
5. What is a priority nursing assessment in the first 24 hours after  Option B: A complete history is not possible in emergency care.
admission of the client with a thrombotic stroke?  Option D: Upcoming surgical procedures will need to be delay if t-
1. Cholesterol level PA is administered.
2. Pupil size and pupillary response 4. Answer: 3. Blood pressure
3. Bowel sounds Controlling the blood pressure is critical because an intracerebral
4. Echocardiogram hemorrhage is the major adverse effect of thrombolytic therapy. Blood
6. What is the expected outcome of thrombolytic drug therapy? pressure should be maintained according to physician and is specific to the
1. Increased vascular permeability. client’s ischemic tissue needs and risks of bleeding from treatment. Other
2. Vasoconstriction. vital signs are monitored, but the priority is blood pressure.
3. Dissolved emboli. 5. Answer: 2. Pupil size and pupillary response
4. Prevention of hemorrhage It is crucial to monitor the pupil size and pupillary response to indicate
7. The client diagnosed with atrial fibrillation has experienced a transient changes around the cranial nerves.
ischemic attack (TIA). Which medication would the nurse anticipate being  Option A: Cholesterol level is an assessment to be addressed for
ordered for the client on discharge? long-term healthy lifestyle rehabilitation.
1. An oral anticoagulant medication.
2. A beta-blocker medication.
 Option C: Bowel sounds need to be assessed because an ileus
or constipation can develop, but is not a priority in the first 24
3. An anti-hyperuricemic medication.
hours.
4. A thrombolytic medication.
8. Which client would the nurse identify as being most at risk for  Option D: An echocardiogram is not needed for the client with a
experiencing a CVA? thrombotic stroke.
1. A 55-year-old African American male. 6. Answer: 3. Dissolved emboli.
2. An 84-year-old Japanese female. Thrombolytic therapy is used to dissolve emboli and reestablish cerebral
3. A 67-year-old Caucasian male. perfusion.
4. A 39-year-old pregnant female. 7. Answer: 1. An oral anticoagulant medication.
9. Which assessment data would indicate to the nurse that the client would Thrombi form secondary to atrial fibrillation. Therefore, an anticoagulant
be at risk for a hemorrhagic stroke? would be anticipated to prevent thrombi formation; and oral
1. A blood glucose level of 480 mg/dl. (warfarin[Coumadin]) at discharge versus intravenous.
2. A right-sided carotid bruit.  Option B: Beta blockers slow the heart rate and lower the blood
3. A blood pressure of 220/120 mmHg. pressure.
4. The presence of bronchogenic carcinoma.  Option C: Anti-hyperuricemic medication is given to clients with
10. The nurse and unlicensed assistive personnel (UAP) are caring for a gout.
client with right-sided paralysis. Which action by the UAP requires the
nurse to intervene?
 Option D: Thrombolytic medication might have been given at
initial presentation but would not be a drug prescribed at
1. The assistant places a gait belt around the client’s waist prior to
discharge.
ambulating.
8. Answer: 1. A 55-year-old African American male.
2. The assistant places the client on the back with the client’s head to the
African Americans have twice the rate of CVA’s as Caucasians; males are
side.
more likely to have strokes than females except in advanced years.
3. The assistant places her hand under the client’s right axilla to help him/her
move up in bed.  Option B: Oriental’s have a lower risk, possibly due to their high
4. The assistant praises the client for attempting to perform ADL’s omega-3 fatty acids.
independently.  Option D: Pregnancy is a minimal risk factor for CVA.
9. Answer: 3. A blood pressure of 220/120 mmHg.
Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a
ruptured blood vessel in the cranium.
1. Answer: 1. Placing the client on the back with a small pillow under the
 Option A: High blood glucose levels could predispose a patient to
head.
ischemic stroke, but not hemorrhagic.
  Option B: Bruit in the carotid artery would predispose a client to
an embolic or ischemic stroke.
 Option D: Cancer is not a precursor to stroke.
10. Answer: 3. The assistant places her hand under the client’s right axilla
to help him/her move up in bed.
This action is inappropriate and would require intervention by the nurse
because pulling on a flaccid shoulder joint could cause shoulder dislocation;
as always use a lift sheet for the client and nurse safety.
Options A, B, and D: All the other actions are appropriate.